Basic Information
| Provider Information | |||||||||
| NPI: | 1225027097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WELCH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 449 MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077544559 | ||||||||
| FaxNumber: | 3077547733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1613 STAMPEDE AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CODY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824144710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075879800 | ||||||||
| FaxNumber: | 3075879830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 6582A | WY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 116620400 | 05 | WY | MEDICAID | 315520 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 311069 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 020050984 | 01 | WY | RAILROAD MEDICARE | OTHER |